清创、抗生素及植入物保留治疗晚期急性血源性人工关节感染的疗效

Outcome of Debridement, Antibiotics, and Implant Retention for Treatment of Late Acute Hematogenous Periprosthetic Joint Infections.

作者信息

Chandler Calvin C, Frandsen Jeffrey J, McHugh Michael A, Graham Stephen D, Fehring Thomas K, Otero Jesse E

机构信息

Atrium Health Musculoskeletal Institute, Charlotte, North Carolina.

Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina.

出版信息

J Arthroplasty. 2025 Jul 17. doi: 10.1016/j.arth.2025.07.008.

DOI:10.1016/j.arth.2025.07.008

PMID:40683392

Abstract

BACKGROUND

Late acute hematogenous periprosthetic joint infections (LAHPJIs) pose a unique challenge to the arthroplasty surgeon. While debridement, antibiotics, and implant retention (DAIR) is a common method for treatment, success rates vary widely. Our study aimed to provide clarity on the efficacy of DAIR in treating LAHPJIs, as well as to identify factors associated with treatment success, which may guide decision-making for optimizing patient outcomes.

METHODS

A retrospective review of all LAHPJI cases treated with DAIR from 2010 to 2020 at a single institution was performed. A LAHPJI was defined as symptoms < four weeks in a joint that is > three months from surgery. A PJI was defined by the Musculoskeletal Infection Society criteria. Patients were classified based on McPherson classification, which includes host type (A, B, or C) and extremity grade (1, 2, or 3). Failure was defined as recurrent infection. In total, 152 LAHPJIs (110 knees, 42 hips) were included with a median follow-up of 6.4 years.

RESULTS

Kaplan-Meier analysis demonstrated 75% infection-free survival at five years, with 70.7% of failures occurring within the first year after DAIR. McPherson systemic host grade significantly predicted the success of DAIR, with failure rates of 8.7, 24.4, and 40% in type A, B, and C hosts, respectively (P = 0.02). Multivariable regression revealed that type C hosts were 5.3 times more likely to fail treatment than type A (95% confidence interval 1.06 to 26.75, P = 0.04). Polymicrobial infections were most common (30.3%), followed by methicillin-sensitive Staphylococcus aureus (16.4%).

CONCLUSIONS

A DAIR is a viable treatment option for LAHPJI, especially in type A hosts. Careful history should confirm symptoms for less than four weeks. Patients who have a high comorbidity burden and elevated preoperative inflammatory labs should be monitored closely for treatment failure.

摘要

背景

晚期急性血源性人工关节周围感染（LAHPJIs）给关节置换外科医生带来了独特的挑战。虽然清创、抗生素和保留植入物（DAIR）是一种常见的治疗方法，但其成功率差异很大。我们的研究旨在明确DAIR治疗LAHPJIs的疗效，并确定与治疗成功相关的因素，这可能有助于指导决策以优化患者预后。

方法

对2010年至2020年在单一机构接受DAIR治疗的所有LAHPJI病例进行回顾性研究。LAHPJI定义为手术后超过3个月的关节出现症状且持续时间小于4周。假体周围感染（PJI）根据肌肉骨骼感染协会标准定义。患者根据麦克弗森分类法进行分类，该分类法包括宿主类型（A、B或C）和肢体等级（1、2或3）。治疗失败定义为感染复发。共纳入152例LAHPJIs（110例膝关节，42例髋关节），中位随访时间为6.4年。

结果

Kaplan-Meier分析显示，五年时无感染生存率为75%，70.7%的治疗失败发生在DAIR后的第一年内。麦克弗森全身宿主等级显著预测了DAIR的治疗成功，A、B和C型宿主的失败率分别为8.7%、24.4%和40%（P = 0.02）。多变量回归显示，C型宿主治疗失败的可能性是A型宿主的5.3倍（95%置信区间1.06至26.75，P = 0.04）。混合感染最为常见（30.3%），其次是对甲氧西林敏感的金黄色葡萄球菌（16.4%）。